Our office staff has seen a trend in in the past 3-4 years as the health insurance premiums have continued to rise along with the deductibles for most people. As an orthopedic surgeon’s office, we typically see patients who are concerned that they have an injury or condition that ultimately may need surgery. Countless times, we are asked whether or not they should use or not use their insurance for their consultation visit and potential diagnostic imaging studies.Here is a very common situation we have encountered in our practice. A person has a knee problem that hasn’t improved after seeing their family doctor, having x-rays and possibly even trying physical therapy or medications. The result is usually a referral to a specialist for further work up and diagnosis if the symptoms persist more than 6-8 weeks. The patient has a friend or family member who have also lead the them to believe that based on the symptoms, they have a meniscus tear and will probably need surgery to get it fixed.So, the patient calls the office and says, should I see you and use your deeply discounted direct pay rate or have you bill my insurance? Or maybe it’s a plan we don’t have a contract with at all (making Dr. Tadych out of network with their insurance). So, should they try to let insurance apply it to their out of network deductible or pay cash? One thing is for sure, people have become better consumers when it comes to their medical expenses because of the rise in healthcare costs overall. As a consumer, you have to ask yourself, how much of my deductible has not been met this year? What is my estimate for out of pocket expenses moving forward?

DO THE MATHLet’s say, you only went to see your family doctor 2 times and had the one set of x-rays. The amount that was applied to your deductible was nominal in comparison to the annual deductible you have to meet before anything is covered. The best place to find this information is on the statement or explanation of benefits that is sent to you from your insurance company. Most of them are pretty easy to understand, and there is always a phone number to call if you have questions.The statement will show you the date of service and an itemized description of the services, the amount billed to your insurance, contract discounts and what you owe or what is applied to your deductible.

Office visit applied to deductible $115 x 2 (visits)

X-rays for the knee were also applied to deductible $85

The total $315 applied to your deductible for the knee problem.Your annual deductible is $___________, let’s say $6000 for our example here.Your remaining deductible is $5,685 (assuming these were the only medical visits you have had).So, now you need to get yourself an estimate on costs that you think you might incur. So, let’s go out to Dr. Tadych’s site and price out some of our services!

Specialist visit

as a first time patient, this will probable run about $159 (visits are based on complexity and patient’s health history)

maybe an MRI

Our website also lists out some low cost MRI facilities in the state if you are willing to travel to save thousands! $600 for MRI @ Smart Choice in Appleton.

another follow up visit with the specialist to get the results and discuss options for treatment.

For a follow up and review if your MRI, we will use the average price of $119.

probably surgery (since your friends and family have convinced you that you tore your meniscus)

The surgery to treat your meniscus will cost about $3200 (doctor-direct price) and includes 3 months of post op care with no complications.

Your total estimated cost by not using insurance and taking advantage of the direct pay model is $4078! You’re still $1600 under your remaining deductible! If you elect to use your insurance, your surgery bills alone could be over $8500, of which most will be applied to your unmet deductible. Remember, you had $5685 remaining deductible plus yourco-insurance(%). The best advice we can give you is to contact your insurance company and request an estimate on your out of pocket expenses for any upcoming services you are considering. Wisconsin law states that members have the right to request a good faith estimate from their insurance company.